Fighting the Insurance Fight

[Here’s where I’d like to remind everyone – on the off chance that you’d forgotten – that nothing in the world of health insurance makes sense. Not. A. Single. Thing.]

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In my January post, I mentioned that Gavin was getting his trial talker in February. He got it and LOVED it but it was only a trial so after 30 days we had to send it back. That’s when the fun started. His hospital speech therapist had to work with the school and his pediatrician to write up a report that would prove to insurance that this talker was important. Not just for social development – which is super important but more importantly for cognitive development. Gavin is a super smart kid it’s just his body doesn’t work which can make any kind of learning challenging, especially when it’s hard to measure how much he is taking in (which for the record is a lot more than I think people give him credit for).
 
After what seemed like an eternity (ok so maybe a month) all the documents were submitted to the insurance company. The wait was on. We were told that once everything is submitted to insurance, they have 90 days to respond. That response can be in the from of “approved” “denied” or “we have questions”. With the last response, the clock resets and the 90 days starts over again. Since a talker isn’t seen as medically necessary, the first response is typically “denied!” (I always imagine with a huge red stamp but it never actually comes to us that way). 
 
Since we had nothing else going on during this time, we figured we’d visit the CP equipment clinic in Boston. Gavin keeps breaking his adaptive stroller so we were pretty sure it was time for an upgrade. The equipment specialists were pretty amazed by the different locations where Gavin has broken his chair. Metal bolts, seat plates, side laterals (normal occurrence really), back support panels…you name and he’s broken it, at least once. Gavin was fitted for a brand new tilt in space wheelchair. He helped pick out the colors and even provided some input on a few other accessories. Once again, we wait. Reports have to be written, supporting documents from his pediatrician need to be obtained, it’s endless really. But the report was finally submitted to insurance for review. Now we figured, “hey this is durable medical equipment, which IS covered under my insurance and it IS medically necessary so it shouldn’t take long to approve.” 
 
[Here’s where I’d like to remind everyone – on the off chance that you’d forgotten – that nothing in the world of health insurance makes sense. Not. A. Single. Thing.]
 
Within a month of the talker claim being submitted the talker was APPROVED! No questions, no push back, nothing. In fact we already have it in hand and Gavin has already started playing around with it (he begins speech therapy next week!) I almost fell out of the chair the day I read the “approved” letter from the insurance company. 
 
Last week I get a letter from the insurance company with a laundry list of questions regarding his wheelchair (the letter was for his doc’s I just get a copy). Seriously? Something that he urgently needs and relies on isn’t being approved because there are questions??? What could they possibly have questions about?! He needs the tilt in space for everything from transportation to effective communication, eating, drinking, working on hand movements, etc. Gavin needs to have good positioning to be able to eat, drink and communicate because he has low tone in his core – i.e. his torso can’t support him so he needs to be in a device that gives him the support his own body can’t. I’d say that qualifies as medically necessary – and yet we wait. 
  
[Just in case you’re thinking approvals are based solely on cost – the talker actually costs more than the wheelchair.]
 
In the meantime we had his medical equipment folks out to survey the latest damage to his stroller for a repair request. That request has been submitted – to you guessed it – insurance – and so we once again wait. 
 
I truly don’t understand health insurance. I mean at its core I get it – it’s a business BUT a business that’s only mission is to improve the lives of those that subscribe to it. If my insurance company really wanted to be my partner in health, shouldn’t they at least understand what the word partner means? 

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